Malaria Journal This Provisional PDF corresponds to the article as it appeared upon acceptance. Fully formatted PDF and full text (HTML) versions will be made available soon. Determinants of delay in malaria treatment-seeking behaviour for under-five children in south-west Ethiopia: a case control study Malaria Journal 2010, 9:320 doi:10.1186/1475-2875-9-320 Alemayehu Getahun ([email protected]) Kebede Deribe ([email protected]) Amare Deribew ([email protected]) ISSN 1475-2875 Article type Research Submission date 13 September 2010 Acceptance date 11 November 2010 Publication date 11 November 2010 Article URL http://www.malariajournal.com/content/9/1/320 This peer-reviewed article was published immediately upon acceptance. It can be downloaded, printed and distributed freely for any purposes (see copyright notice below). Articles in Malaria Journal are listed in PubMed and archived at PubMed Central. 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Determinants of delay in malaria treatment-seeking behaviour for under-five children in south-west Ethiopia: a case control study Alemayehu Getahun 1, Kebede Deribe 2, Amare Deribew * 3 1Wollega University, Nakamte, Ethiopia; 2 Fayya Development Association, Addis Ababa, Ethiopia; 3Department of Epidemiology, Director of publication and Extension, Jimma University, Jimma, Ethiopia Email addresses: Alemayehu Getahun: [email protected] Kebede Deribe: [email protected] Amare Deribew: [email protected] * Corresponding author Abstract Background Prompt diagnosis and timely treatment of malaria within 24 hours after onset of first symptoms can reduce illness progression to severe stages and therefore, decrease mortality. The reason why mothers/caretakers delay in malaria diagnosis and treatment for under-five children is not well studied in Ethiopia. The objective of this study was to assess determinants of malaria treatment delay in under-five children in three districts of south-west Ethiopia. Methods A case control study was conducted from March 15 to April 20, 2010. Cases were under-five children who had clinical malaria and sought treatment after 24 hours of developing sign and symptom, and controls were under-five children who had clinical malaria and sought treatment within 24 hours of developing sign and symptom of malaria. Data were collected by trained enumerators using structured questionnaire. Data were entered in to Epi Info version 6.04 and analyzed using SPSS version 16.0. To identify determinants, multiple logistic regression was done. Results A total of 155 mothers of cases and 155 mothers of controls were interviewed. Mothers of children who were in a monogamous marriage (OR=3.41, 95% CI: 1.39, 8.34), who complained about the side effects of anti-malarial drugs (OR=4.96, 95% CI: 1.21, 20.36), who had no history of child death (OR=3.50, 95% CI: 1.82, 6.42) and who complained about the higher cost of transportation to reach the health institutions (OR=2.01, 95% CI: 1.17, 3.45) were more likely to be late for the treatment of malaria in under-five children. Conclusion Effective malaria control programmes should address reducing delayed presentation of children for treatment. Efforts to reduce delay should address transport cost, decentralization of services and increasing awareness of the community on early diagnosis and treatment. Background By the mid-20th century, malaria was eliminated as a major health problem in many part of the world. In many parts of sub-Saharan Africa, it is still the largest contributor to the burden of disease and premature death [1-3]. During the past decades, numerous large-scale initiatives have been undertaken with the goal of reducing or eradicating the burden of malaria in the developing world. However, the ambitious goals set by these programmes for reducing the burden of malaria in the near future appear unlikely to be met [4]. Mortality from malaria is the major burden in under-five children. Most deaths occur at the community level, outside the health institution. Effective treatment exists, but it must be administered promptly and timely by trained personnel in order to be effective [5, 6]. In Africa, an estimated 300-500 million cases of malaria occur each year resulting in approximately one million deaths. Among death due to malaria occurring in Africa more than 90% are in under-five children that results in brain damage [7-9]. However, it is generally accepted that most malaria deaths can be prevented when clinical cases are promptly diagnosed and effectively treated. Major factors affecting the outcome of the diseases are health-seeking behaviour and socio-economic status, which determine access to health services [2]. In young children, malaria can progress from a mild to severe case within 24 hours after the onset of symptoms. Prompt diagnosis and timely malaria treatment within 24 hours after onset of first symptoms can reduce illness progression to severe stages and, therefore, decrease mortality [10, 11]. In Ethiopia, acute febrile illnesses are the leading causes of morbidity and mortality among under-five children [12-14]. Over five million episodes of malaria are estimated to occur annually and it is the top leading cause of outpatient visit and inpatient mortality [15, 16]. The Ethiopian malaria control and prevention strategy gives due emphasis for early diagnosis and prompt treatment [17]. However, children with malaria often times seek treatment in the late stage of the disease. Information concerning determinants of malaria treatment delay in under- five children is insufficient in Ethiopia. Therefore, this study could contribute to understanding determinants of malaria treatment delay for under-five children in local context, which is essential for malaria control in children. Methods Study area and period A case control study was conducted from March 15 to April 20, 2010 in six health centres (Nada, Asandabo, Dimtu, Akko, Sokoru and Deneba Health centres) located in Omo Nada, Tiro Afeta and Sokoru Districts in south-west Ethiopia. The three Districts were selected purposively based on their malaria endemicity and all health centres in selected Districts were included. The study health centres are found around the Gilgel Gibe Hydroelectric dam where malaria is known to be endemic [18, 19]. Study population The study population consisted of cases and controls. Cases were under-five children who had one or more signs/symptoms of malaria and positive for plasmodium species based on blood film examination and sought treatment in the health centres after 24 hours of developing sign and symptoms. Controls were under-five children who had one or more signs/symptoms of malaria and positive for Plasmodium species based on blood film examination and sought treatment within 24 hours of developing sign and symptoms at the health centres. Sample size and sampling procedure The sample size was calculated using Epi-Info version 6.04 statistical software. The sample size was calculated by taking distance from health institutions as a main exposure variable. From literature, it was found that proportion of individuals travelling a distance of three kilometres or more to reach the nearby health centre among controls was 27.65% [20]. By considering 80% power, Odds ratio of 2.0, and case to control ratio of 1:1, the total sample size was 310 children (155 cases and 155 controls). The survey was conducted in under-five clinics to identify and register cases and controls. Cases and controls who had malaria in the health centres were included after blood film examination. Children who had fever and negative for Plasmodium falciparum were excluded. Children visiting the health centres during the study period and fulfilling inclusion criteria were recruited till the sample size was achieved. For a case found during data collection, a consecutive control was recruited from the same health centre. The study excluded private facilities since majorities of the private health facilities did not have laboratory facilities and treat malaria empirically based on signs and symptoms. Data collection method and tools Cases and controls were interviewed by trained grade 10 completed students using pre-tested and structured questionnaire. The survey tool was initially prepared in English, and translated to Afan Oromo (local language), and checked for its consistency through back translation to English by three different individuals who were health professionals. The questionnaire had two parts. The first part (socio-demographic section) encompasses age, sex, occupation, educational status, income, ethnicity, marital status, family size and communication materials. In the second part, behavioural factors, such as perception and knowledge of mothers, and health system and infrastructure-related factors were assessed. To assess the knowledge of the respondents, 10 questions related to the signs and symptoms, mode of transmission, prevention and treatment of malaria were asked. For each question, a correct answer was given a score 1 and an incorrect answer a score 0. A total knowledge score was constructed by summing all the scores of the knowledge questions. Individuals who scored above the mean were categorized as knowledgeable. Diagnosis of malaria was made by thick and thin blood films prepared from a finger prick and stained with Giemsa in health centres. Each slide was read by experienced laboratory technicians. Absence of malaria parasite in 200 high power ocular fields of the thick film was considered as negative [11]. Data analysis Data were first checked manually for completeness and then entered into Epi-Info version 6.04.